The role of computed tomography and magnetic resonance imaging in surgical planning for thoracic outlet syndrome: the experience of a single third level reference center for peripheral nerve surgery.

OBJECTIVE: Anatomical abnormalities in the thoracic outlet syndrome are very frequent, but radiological images are not always reliable. Therefore, the different features and abilities of CT angiogram and brachial plexus MRI to detect anatomical abnormalities have been investigated. METHODS: All radiological and surgical records of patients operated for thoracic outlet syndrome between January 2011 and December 2018 were retrospectively analyzed. Considering the CT angiogram and/or brachial plexus MRI reports of the preoperative period, the performance of these investigations was evaluated by calculating the precision (P), sensitivity (Recall) and Hamming loss (L). RESULTS: From a total of 107 patients screened, 84 were eligible for study inclusion. Out of these, 46 had surgical abnormalities (group 1), while 38 did not (group 2). Among them, 30 patients have performed CT angiogram (subgroup A), 32 brachial plexus MRI (subgroup B) and 22 both (subgroup C). The best result is obtained when both diagnostic examinations are performed (subgroup C: P = 0.62; recall = 0.52; L = 0.038). CONCLUSIONS: Prescribing both investigations in selected patients increases the probability of finding anatomic anomalies and facilitates preoperative planning. However, as the radiological images are not completely exhaustive, the surgeon should always actively search and remove any potential source of compression on the nervous vascular bundle along the thoracic outlet.

Functional outcome after transfer of brachialis on anterior interosseous and supinator on posterior interosseous nerves: A preliminary report.

OBJECTIVE: Traumatic spinal cord injury (SCI) resulting in tetraplegia is a leading cause of morbidity among young adults worldwide and its management remains challenging. Restoring hand function in these patients must be considered a top priority with great impact on their quality of life (QOL); although nerve and tendon transfer have been extensively described, type of procedure to be chosen is not standardized and few studies have determined the functional outcome of those procedure and their impact on QOL is still poorly assessed. We report a preliminary retrospective study regarding feasibility and functional outcomes of nerve transfer procedures including bilateral brachialis nerve on anterior interosseous nerve (AIN) and supinator branch on posterior interosseous nerve (PIN) for hand reanimation following SCI focusing on the impact of these procedures on QOL. METHODS: We performed a retrospective study involving patient sustained SCI and underwent nerve transfer of brachialis branch from musculocutaneous nerve on AIN and supinator branch from the trunk of the radial nerve on the PIN. We included 11 patients (14 limbs) with traumatic SCI resulting in C4 level tetraplegia in five patients, C5 in four and C6 and C7 in one case each, with a median age of 31.5 years underwent surgery at a median of 10 months after injury; including both transfers in 10 cases and AIN reanimation only in one. Functional assessment including medical research council (MCR) grade, graded redefined assessment of strength sensation and prehension (GRASSP) and spinal cord independence measure (SCIM) were performed at least 12 months follow up. RESULTS: Thirteen PIN innervated muscles achieved an MRC score ≥3/5 whereas AIN supplied muscles in 5 out of 15. GRASSP qualitative measure improved from a baseline value of 1 to 2, while quantitative measure passed from 1 to 3 after 12 months; the difference was statistically significant (p = .005 and p = .008, respectively). SCIM self-care sub-score also statistically significant improved from 3 to 4 at 12 months (p = .016). No complication or donor morbidity occurred. CONCLUSIONS: Functional performance has been significantly improved by nerve transfer procedures 1 year after surgery. Nerve transfers may represent a valuable option for the restoration of the hand function in patients with tetraplegia with minor or no morbidity.

Surgery in cerebral metastases: are numbers so important?

BACKGROUND: The prognosis of cerebral metastases (MTS) is linked to progression of both systemic and local disease. The importance of MTS resection has been already pointed out. The observation of a high mortality for not-neurological causes confirms that the modern treatments allow a significant control of the disease within the nervous system. Nevertheless, management difficulties increase with multiple lesions and in these cases the role of surgery has still to be defined. MATERIALS AND METHODS: We collected the clinical data of patients operated in two centers for cerebral MTS from lung carcinoma during 8 years. Patient selection for surgery followed definite criteria; the limit for multiple MTS was three. We analyzed the functional and survival outcomes of the cohort. RESULTS AND CONCLUSIONS: Our series included 242 patients: 105 had multiple MTS. Statistical analysis did not show significant differences in mean survival and outcomes between patients with single and multiple lesions. The decease occurred for neurological causes in 15.7% of cases. The selection of candidates for surgery requires several considerations and entails the success rate of this treatment. In patients with the multiple lesions who fulfilled the selection criteria we observed a nevertheless satisfying success after the operation. Our results imply that surgery may be applied also in selected patients with more diffuse intracranial disease. A pre-operative accurate patient selection is related to acceptable quality-of-life following the operation even in cases of multiple MTS.